A Sinister Swelling: A Case Report

Suresh Chelliah

Department of Pediatrics, Kauvery Hospital, Trichy, India

*Correspondence: [email protected]

Case Presentation

An 11-year-old, previously well girl was admitted with complaints of low back pain for 2 months, gradually increasing in severity.

She had difficulty in walking and burning micturition for 2 days and was constipated. On admission she was alert, febrile and refused to walk because of pain. Local examination revealed a diffuse swelling in the right iliac region and right thigh with no warmth or tenderness. No spinal/sacral tenderness or distal neurological deficits were present. Clinical diagnosis was Psoas Abscess and cellulitis.

Her blood counts were normal with mildly elevated CRP, ESR and Procalcitonin. Peripheral smear showed neutrophilic predominance. She had high fever and IV antibiotics were given. Her blood and urine cultures were sterile.

MRI pelvis was planned, but as she couldn’t tolerate the pain, CT was taken. CT showed a mass lesion on right iliacus muscle with destruction of right iliacus bone extending into gluteal muscle and S1 joint.

USG guided biopsy and MRI pelvis was done under sedation. MRI pelvis contrast study showed mass lesion on the right pelvis with compression and displacement of adjacent major blood vessels medially with subcutaneous edema around right thigh and destruction of iliac bone. Biopsy showed small round cell tumor suggestive of Ewings sarcoma. HRCT chest screening showed multiple metastatic lesions in bilateral lung fields.

Child was managed by a team of Paediatricians, Dr. Chockalingam, Orthopedicians, Dr. Anis Surgical Oncologist, Dr K. Senthil Kumar, Anesthesiology and Dr. Vinodh Gunasekaran, Pediatric Hemato-oncologist. As parents desired to continue treatment from Adyar Cancer Institute, she was referred there.

Discussion

Ewing’s sarcoma is the second most common primary malignant bone tumor after osteosarcoma, accounting for three percent of all childhood malignancies [1]. It was first described as “an endothelioma of the bone” by James Ewing in 1921 [2]. It is commonly seen in 5-15 years of age.

Ewings sarcoma of pelvis has poor prognosis because of lack of major anatomic barrier to tumor spread in pelvis and proximity to visceral organs and neurovascular bundles making local control difficult [3,4].

With the introduction of effective chemotherapy, imaging modalities and modern surgical techniques limb salvage procedures has replaced amputation for radical treatment of malignant pelvic bone tumours [5]. Though, in cases where limb salvage is not possible, conservative hemipelvectomy remains a modality of treatment.

Take home message: Children rarely complain of pain without a reason. A small clinical clue may lead us to a diagnosis. Revisiting the case is the best method to reach a logical conclusion.

References

  1. Rodrí­guez-Galindo C, Liu T, Krasin MJ. Analysis of prognostic factors in Ewing sarcoma family of tumors: review of St. Jude Children’s Research Hospital studies. Cancer. 2007;110(2):375-84.
  2. Ewing J. Diffuse endothelioma of bone. Proc NY Pathol Soc. 1921;21:17.
  3. Marcus RB, Springfield DS, Graham-Pole JR, et al. Late follow-up of a short-term intensive regimen for Ewing’s sarcoma. Am J Clin Oncol. 1991;14(5):446-50.
  4. Donati D, El Ghoneimy A, Bertoni F, et al. Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br. 2005;87(11):1527.
  5. O’Connor MI, Sim FH. Salvage of the limb in the treatment of malignant pelvic tumors. J Bone Joint Surg Am. 1989;71(4):481-94.

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